Back to Blog

Endometriosis and Infertility. IVF or Surgery in 2025?

Endometriosis and Infertility. IVF or Surgery in 2025?

Hello, I am Dr. Senai Aksoy. I have been working in the field of in vitro fertilization in Istanbul for over 30 years. In my clinic, I meet couples daily who face endometriosis and the desire to have a child.

The year 2025 marks a turning point in the treatment of infertility related to endometriosis. Current recommendations from ESHRE deliver a clear message: surgery is no longer the first choice. The VODE study has demonstrated the remarkable effectiveness of IVF as the first-line option.

📌 What You Will Learn in This Article:

Why Has the Approach Changed

Since 2022, ESHRE recommendations on endometriosis are clear: surgery should not be performed solely to improve IVF outcomes. Hormonal blocking treatments (GnRH analogs, continuous progestins) are not recommended for fertility purposes as they prevent conception and waste precious time.

In my practice, I observe that unnecessary surgery can affect ovarian reserve. For couples with endometriosis, time is the most precious resource.

The VODE Study: Striking Results

The randomized VODE study (2025) compared two strategies in women with ovarian or deep endometriosis:

IVF-first group:

Surgery-first group:

IVF doubles the success rate.

When Surgery Remains Necessary

Surgery maintains its place in specific situations:

  1. Severe pain: When medical treatment fails and pain disrupts daily life.

  2. Endometrioma >3 cm: ESHRE suggests that surgery may increase spontaneous pregnancy chances for endometriomas larger than 3 cm.

  3. Hydrosalpinx: An obstructed tube must be removed before embryo transfer as its fluid is toxic.

  4. Mechanical obstacle: Adhesions preventing ovarian access for retrieval.

  5. EFI score: The Endometriosis Fertility Index calculated after surgery predicts natural pregnancy chances. If ≤6, immediate transition to ART.

2025 Treatment Algorithm

Situation 1: Infertility + Severe Pain

Situation 2: Infertility + Absent/Controlled Pain

Optimized IVF Protocols

PPOS: The New Standard

The PPOS protocol (Progestin Primed Ovarian Stimulation) uses progestins to control the cycle. All embryos are frozen then transferred later.

Advantages: shorter stimulation, fewer medications, equivalent or better birth rates.

Down-Regulation: No Longer Routine

ESHRE confirms that long pre-IVF suppression does not systematically increase live births. Reserved for selected cases.

Oocyte Quality: A Myth Shattered

A 2025 review challenges our certainties about oocyte quality in endometriosis. New evidence shows normal fertilization rates and chromosomal quality; the real problem is the toxic pelvic environment, not the oocyte itself.

Microbiota and Ferroptosis

Systemic Vision of Endometriosis

Endometriosis is now viewed as a systemic inflammatory disease linked to the microbiota. Intestinal dysbiosis, passage of bacterial toxins and altered estrogen metabolism contribute to chronic inflammation. Vaginal microbiota before transfer predicts success: Lactobacillus-dominant flora yields higher pregnancy rates.

Ferroptosis: Iron Toxicity

Ferroptosis is cell death by iron overload. Endometriotic cells show iron resistance, while oocytes are vulnerable. Iron chelation therapies may protect fertility.

Non-Hormonal Treatments in Development

New approaches aim to target inflammation without blocking ovulation. JNK inhibitors are promising for lesion regression and are in early trials:contentReference[oaicite:0]{index=0}.

Frequently Asked Questions

  1. Why is IVF now preferred over surgery in endometriosis?
    Because the VODE study showed the IVF‑first strategy doubles the live birth rate. Surgery can damage ovarian reserve and waste time.

  2. Should endometriomas always be operated on before IVF?
    No. I operate on endometriomas only when there is uncontrolled pain, large size or suspicion of malignancy. For asymptomatic cysts, direct IVF gives better results.

  3. How many IVF cycles are needed with endometriosis?
    In our Istanbul clinic, most patients achieve pregnancy within the first 1–2 cycles using optimized protocols.

  4. Does vaginal microbiota really influence IVF results in endometriosis?
    Yes. Research shows Lactobacillus dominance is associated with higher pregnancy rates. We screen and treat dysbiosis before transfer.

  5. What new non-hormonal treatments are available for endometriosis?
    New therapies targeting inflammatory pathways are under development, including JNK inhibitors:contentReference[oaicite:1]{index=1}. These aim to relieve pain without suppressing ovulation.

Conclusion: The New Era of Treatment

2025 marks a major turning point: IVF as first-line treatment, selective surgery, optimized protocols, and a systemic view of endometriosis. In our IVF clinic in Istanbul, we tailor strategies to each patient.

Schedule an appointment for a personalized consultation to discuss your situation.

📚 Scientific Summary

✔ ESHRE 2022-2025: No surgery to improve IVF only:contentReference[oaicite:2]{index=2}
✔ VODE 2025: IVF‑first 46% vs surgery‑first 23% live births
✔ Microbiota 2025: Vaginal Lactobacillus dominance improves pregnancy rates
✔ Ferroptosis 2025: Iron toxicity affects oocyte quality and reserve

Date of publication: November 3, 2025. This article by Dr. Senai Aksoy is informational. Each patient is unique. IVF results vary according to many factors. Always consult a specialist for your personal situation.

© 2025 Dr. Senai Aksoy - All rights reserved

Dr. Senai Aksoy

Dr. Senai Aksoy

Dr. Senai Aksoy is a renowned expert in the field of reproductive medicine, with over 20 years of experience. He has dedicated his career to helping couples achieve their dreams of parenthood through advanced fertility treatments and personalized care.

The content has been created by Dr. Senai Aksoy and medically approved.